General Information

• 1) Named Insured(s) *
• 1a) Federal ID
• 2) Address *
• 3) Business Phone *
• 3a) Cell Phone
• 4) Email Address *
• 5) Number of Locations?

  If more than one (1) please complete sections XX for each location

• 6) Are there any locations or business interests which are owned by the applicant but not shown on this application? Yes No

Location Information

• Location Number
• Address
• 7) Type of Restaurant? Fast Food Casual Dining Fine Dining Restaurants – No Cooking/No Frying and Limited Seating Restaurants – WITH Cooking and Limited Seating Other than shown
• 8) Is the restaurant a franchise? Yes No
• 9) What is the primary type of cuisine?
• 10) Number of Employees
• 10a) Full Time
• 10b) Part Time
• 11) Does the restaurant regularly provide meal/food delivery? Yes No
• 12) What is the year the business was established or acquired at this location?
• 13) How many years management/ownership experience does applicant have in this industry?
• 14) Total annual gross receipts at this location $
• 15) Catering receipts at this location $
• 16) What are the total annual receipts generated from serving alcohol at this location? $
• 17) Indicate the location type Stand-alone building Located in a strip shopping center Attached or within buildings with residential apartments or condos Attached to or within office buildings Attached to or within a mixed occupancy bldg without residential exposures Attached to or within a hotel/motel Located in an enclosed mall Other than described above
• 18) Hours of operation at this location
• Open
• Close
• 19) Total square footage occupied by the applicant
• 20) Total square footage of the public area

  NOTE: Public Area is defined as the total square footage of all areas where the public is permitted to go, such as dining areas & lounges, hallways, stairs, rest rooms, waiting areas & dance floors. Public area does not include kitchens, storage, behind the counter or bar & outside driveways for drive thru service. Please contact your underwriter if you have questions regarding public area.
  ** Infrequently used function rooms and seasonal patios rated at 1/2 the square footage. **

• 21) Seating Capacity

  Note: Seating capacity is the number of seats available for restaurant patrons.

• 22) Indicate the type of entertainment provided at this location None Live Band or DJ Mechanical Rides Dartboards
• 22a) Number of video games Number of Televisions?
• 22b) Number of Pool or Gaming Tables?
• 22c) Other than listed?
• 23) Is there a video surveillance system at this location? Yes No
• 24) Is the restaurant responsible for the parking lot? Yes No
• 25) Is there a drive-through at this location? Yes No
• 26) Are there any playgrounds at this location? Yes No
• 27) What percentage of the building does the restaurant occupy?
• 28) If less than 100%, what percentage is occupied by the following types of operations?
• 28a) Habitation/Apartment %
• 28b) Auto Service/Repair %
• 28c) Bars/Pubs/Taverns %
• 28d) Grocery Store %
• 28e) Offices %
• 28f) Other Restaurants %
• 28g) Retail stores %
• 28h) Other than above %
• 29) What percentage of the building is vacant or unoccupied?
• 30) Any claims sexual abuse or molestation, discrimination or hiring? Yes No

Cooking Operations (complete if applicable)

• 31) Indicate the type of fully operational automatic fire extinguishing system covering all hoods, ducts and cooking equipment Dry Chemical UL 300 Wet Chemical Water Spray Other None
• 32) How often is the automatic fire extinguishing system inspected and serviced by a contracted outside firm? Monthly Quarterly Semi-Annual Annual Never
• 33) How often are flues and ducts inspected and cleaned by a contracted outside firm? Monthly Quarterly Semi-Annual Annual Never
• 34) How often is cooking equipment exhaust filters cleaned? Daily Weekly Monthly Quarterly Semi-Annual Annual Never
• 35) Is any table-side service provided which involved open flames? Yes No
• 36) Are they any deep fat fryers on the premises? Yes No
• 36a) If yes, do the fryers have thermostats, fuel cut-offs and proper ventilation? Yes No

Liquor Liability (complete if applicable)

• 37) Liquor License? Yes No
• 37a) If yes, license number
• 38) Is there a separate bar area? Yes No
• 38a) Does the bar area close later than the dining area? Yes No
• 39) Are drink promotions, such as happy hours, 2-For-1 specials or ladies night offered? Yes No
• 40) Does the restaurant allow patrons to bring their own (BYO)? Yes No
• 41) Have there been any prior liquor citations? Yes No
• 42) Has there been prior liquor liability coverage? Yes No
• 43) Are all employees that serve alcohol given formal alcohol service training, such as TIPS? Yes No
• 44) Does the restaurant have a written policy covering alcohol service guidelines? Yes No
• 45) Are alcohol related incidents documented? Yes No

Automobile Related Operations/Valet Parking (complete if applicable)

• 46) Does the restaurant provide valet parking at this location? Yes No
• 47) Have there been any valet parking losses? Yes No
• 48) Are keys regularly left in the vehicles after they are parked? Yes No

Property Section

• 49) Property, Do you own the building?
• 50) If you rent the building are you required by lease to insure? Yes No
• 50a) If Yes, Please provide the copy of lease section describing your insurance obligations
• 51) Building # 1 Value
  $
• 51a) Building Personal Property Value
  $

  Complete one application for each location

• 52) Your Building Improvements
• 53) Building Age
• 53a) Building Construction Wood Frame Joisted Masonary Masonary Non-Combustible Steel
• 54) Year of any Building Updates, Roof
• Electrical
• Plumbing
• Heating
• 55) Type of roof Shingle Tar Rubber Steel
• 56) Number of Floors?
• 56a) Basement? Yes No
• 56b) Distance to fire hydrant
• 56c) Distance to fire station
• 57) Sprinklered? Yes No
• 57a) What %?
• 57b) Any fire suppression stand pipes etc? Yes No
• 58) Alarmed? Burglar Fire
• 58a) Alarmed to? Central Station Gong Reporting
• 59) Is there a formal safety program in place? Yes No
• 59a) Handbook?
• 60) Have you had insurance declined, cancelled, or non renewed last 3 years Yes No
• 61) Any uncorrected fire or safety code violations in the last 3 year’s? Yes No
• 61a) Bankruptcy in the last 5 years? Yes No
• 62) Any conviction of crime or arson related to property last 5 years? Yes No
• 63) Has business been placed in a trust? Yes No
• 63a) If yes, name of trust
• 64) Any other named additional insured i.e. bank, leasing co. etc?
• 65) Describe Restaurant Experience of owner and or management team running your entity?

Workers compensation

• 66) Type of Entity? Corporation LLC Sole Proprietorship Partnership Other
• 66a) If other
• 67) Corp Officers/Owners, Title/Office, % of Ownership
• 68) Estimated Payroll Restaurant Workers $
• 68a) Workers $
• 68b) Management $
• 68c) Clerical $
• 69) Number of Employees
• 69a) Full Time
• 69b) Part Time